Upper and Lower Gastrointestinal and Hepatobiliary surgery in adults

Upper and Lower Gastrointestinal and Hepatobiliary surgery in adults - Guideline for Antimicrobial Prophylaxis

Publication: 14/08/2009

Next review: 18/03/2025

Clinical Guideline

CURRENT

ID: 1761

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Antimicrobial Prophylaxis in Upper and Lower Gastrointestinal and Hepatobiliary surgery in adults

RECOMMENDED ROUTINE PROPHYLAXIS OPTIONS

See intra-operative re-dosing guidance below for operations lasting 3 or more hours.

Table 1 Acute/emergency
Table 2 Elective
Appendix 1 Dosing and re-dosing summary

Table 1: ACUTE/EMERGENCY

Note: Dosing in patients on antibiotic treatment pre-operatively

See appendix 1 for dosing and re-dosing summary.

Procedure	Antimicrobial dose/route Give ≤1 hour before procedure
Procedure	Routine	MRSA Colonised¹ or penicillin allergy	Colonised by a coliform² (e.g., E.coli) resistant to cefuroxime or ciprofloxacin or an ESBL, AMPC or CPE
Appendicectomy Open or laparoscopic	Follow Appendicitis treatment guideline	Teicoplanin ³ 400mg IV plus Appendicitis treatment guideline	Discuss with microbiology⁵ as early as possible before surgery.
Biliary	Cefuroxime 1.5 grams IV and Metronidazole IV 500mg	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Colorectal surgery via laparotomy/ laparoscopic surgery. Includes small and large bowel surgery.	Cefuroxime 1.5 grams IV and Metronidazole IV 500mg	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Hernia repair	Co-amoxiclav 1.2g IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Liver	Co-amoxiclav 1.2g IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Oesophageal	Cefuroxime 1.5 grams IV and Metronidazole IV 500mg	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Splenectomy See: LTHT Guideline for infection prevention post splenectomy	NOT recommended except in immunosuppressed patients.⁷	NOT recommended except in immunosuppressed patients.⁷	Discuss with microbiology⁴ as early as possible before surgery.
Stomach & duodenal	Cefuroxime 1.5 grams IV and Metronidazole 500mg IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg

Table 2: ELECTIVE

Procedure	Antimicrobial dose/route Give ≤1 hour before procedure
Procedure	Routine	MRSA Colonised¹ or penicillin allergy	Colonised by a coliform² (e.g., E.coli) resistant to cefuroxime or ciprofloxacin or an ESBL, AMPC or CPE
Appendicectomy Open or laparoscopic	Follow Appendicitis treatment guideline	Teicoplanin ³ 400mg IV plus Appendicitis treatment guideline	Discuss with microbiology⁵ as early as possible before surgery.
Bile duct surgery (not gall bladder laparoscopic day case)	Cefuroxime 1.5 grams IV and Metronidazole 500mg IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴
Colorectal surgery via laparotomy/ laparoscopic surgery. Includes small and large bowel surgery	Cefuroxime 1.5 grams IV and Metronidazole 500mg IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴
Endoscopic procedures: Diagnostic	Not recommended	Not recommended	Not applicable
Endoscopic procedures (ERCP & PEG): Therapeutic	See gastrointestinal endoscopy guideline	See gastrointestinal endoscopy guideline
Gall bladder (laparoscopic day case low risk)	Not recommended	Not recommended	Not applicable
Gastric bypass surgery	Co-amoxiclav 1.2g IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Hernia repair	Co-amoxiclav 1.2g IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Liver surgery (excluding transplant)	Co-amoxiclav 1.2g IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Oesophageal	Cefuroxime 1.5 grams IV and Metronidazole IV 500mg	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Pancreatic surgery	Cefuroxime 1.5 grams IV and Metronidazole 500mg IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁵ as early as possible before surgery.
Splenectomy See: LTHT Guideline for infection prevention post splenectomy	NOT recommended except in immunosuppressed patients.⁶	NOT recommended except in immunosuppressed patients.⁶	Discuss with microbiology⁴ as early as possible before surgery.
Stomach & duodenal surgery (excluding gastric bypass)	Cefuroxime 1.5 grams IV and Metronidazole 500mg IV	Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg	Discuss with microbiology⁴ as early as possible before surgery.
Surgery with prosthesis (e.g., gastric band or rectopexy)	NOT recommended except in high risk patients^5/6	NOT recommended except in high risk patients^5/6

MRSA risk = previous MRSA infection or known colonisation
Coliforms include E.coli, Enterobacter, Klebsiella, Serratia, Citrobacter and proteus.
Teicoplanin takes 15 minutes to reconstitute
Antibiotic choice will consider which antibiotics resistance has been detected to detected, the type of resistance, the timing the resistance was detected, recent antibiotic use (which may have selected out resistance), an individual’s risk of infection and the consequence of infection.
High risk - conversion to laparotomy, pregnancy, immunosuppression, insertion of prosthetic devices.
In immunosuppressed/high risk patients give: Co-amoxiclav 1.2g IV or in MRSA Colonised or penicillin allergy give Teicoplanin ³ 400mg IV & Ciprofloxacin 400mg IV & Metronidazole IV 500mg

Redosing intra-operatively
Time based re-dosing
Every 3 hours redose Flucloxacillin, Every 4 hours redose Co-amoxiclav and Cefuroxime , Every 8 hours redose Metronidazole , every 12 hours re-dose Ciprofloxacin . Do not give another dose of Teicoplanin

Blood loss based re-dosing
Re-dose if blood loss is estimated to exceed 1.5 Litres during surgery.

Note: If a surgeon attends a complex case for a particular procedure, they should be asked if there are additional antibiotic requirements.

Appendix 1: Dosing and re-dosing summary.

Antibiotic prophylaxis choice
Procedure	Routine	MRSA Colonised or penicillin allergy
Biliary	Cefuroxime /Metronidazole	Teicoplanin Ciprofloxacin Metronidazole
Colorectal surgery	Cefuroxime /Metronidazole
Hernia repair	Co-amoxiclav
Liver	Co-amoxiclav
Oesophageal	Cefuroxime /Metronidazole
Stomach/ duodenal	Cefuroxime /Metronidazole

Antibiotic dose and re-dosing in relation to time of surgery (time of incision)
*Antibiotic received before* theatre**	*Number of hours before* surgery antibiotics given**	To be given in theatre (Antibiotic surgical prophylaxis)
*Antibiotic received before* theatre**	*Number of hours before* surgery antibiotics given**	< 1 hour before	Intra-operative re-dosing Maximum 3 doses
Co-amoxiclav	Given > 1 hour before	Co-amoxiclav 1.2g IV (minimum dosing interval 60 minutes )	Co-amoxiclav 1.2g IV 4-hourly
Co-amoxiclav	Given < 1 hour before		From time of last dose: Co-amoxiclav 1.2g IV 4-hourly
Cefuroxime	Given > 1 hour before	Cefuroxime 1.5g IV (minimum dosing interval 60 minutes)	Cefuroxime 1.5g IV 4-hourly
Cefuroxime	Given < 1 hour before		From time of last dose: Cefuroxime 1.5g IV 4-hourly
Piperacillin/tazobactam	Given > 1 hour before	Piperacillin/tazobactam 4.5g IV (minimum dosing interval 60 minutes )	Piperacillin/tazobactam 4.5g IV 4-hourly
Piperacillin/tazobactam	Given < 1 hour before		From time of last dose: Piperacillin/tazobactam 4.5g IV 6-hourly
Ciprofloxacin	Given > 6 hour before	Ciprofloxacin 400mg IV	Ciprofloxacin 400mg IV 6-hourly
Ciprofloxacin	Given < 6 hour before		From time of last dose: Ciprofloxacin 400mg IV 6-hourly
Metronidazole	Given > 6 hour before	Metronidazole 500mg IV	Metronidazole 500mg IV 8-hourly
Metronidazole	Given < 6 hour before		From time of last dose: Metronidazole 500mg IV 8-hourly
Teicoplanin	Given > 6 hours before	Teicoplanin 400mg IV	From time of last dose: Teicoplanin 400mg IV 12-hourly
Teicoplanin	Given < 6 hours before		From time of last dose: Teicoplanin 400mg IV 12-hourly

Provenance

Record:	1761
Objective:
Clinical condition:	Gastrointestinal pathology
Target patient group:	Adults
Target professional group(s):	Secondary Care Doctors Secondary Care Nurses Pharmacists
Adapted from:

Evidence base

SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2014.
Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. 2006. p. 589-608.
Infection Control and Hospital Epidemiology November 2008, vol. 29, no. 11 Australian Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections: Annual Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007
Fenton P et al. Journal Hospital Infection 68, (4), April 2008, Pages 376-37 Clostridium infection following hip surgery.
Kirby A, Asín-Prieto E, Burns FA, Ewin D, Fatania K, Kailavasan M, Nisar S, Pericleous A, Trocóniz IF, Burke D. Colo-Pro: a pilot randomised controlled trial to compare standard bolus-dosed cefuroxime prophylaxis to bolus-continuous infusion-dosed cefuroxime prophylaxis for the prevention of infections after colorectal surgery. Eur J Clin Microbiol Infect Dis. 2019 Feb;38(2):357-363.
Dubinsky-Pertzov B, Temkin E, Harbarth S, Fankhauser-Rodriguez C, Carevic B, Radovanovic I, Ris F, Kariv Y, Buchs NC, Schiffer E, Cohen Percia S, Nutman A, Fallach N, Klausner J, Carmeli Y; R-GNOSIS WP4 Study Group. Carriage of Extended-spectrum Beta-lactamase-producing Enterobacteriaceae and the Risk of Surgical Site Infection After Colorectal Surgery: A Prospective Cohort Study. Clin Infect Dis. 2019 May 2;68(10):1699-1704.

Approved By

Improving Antimicrobial Prescribing Group

Document history

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